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The recent BMA report Streets of Shame highlights the growing crisis in healthcare provision for homeless people and indicates that the UK’s rise in homelessness is now a public health disaster.1 According to the report, the average age of death among homeless people is 47 for a man and 43 for a woman; 597 people died while they were homeless in 2017, the highest number on record. Attendance at emergency departments by people experiencing homelessness trebled from 2011 to 2018.1 The same period saw a steep rise in admissions: from 3378 to 9282.1

The charity Crisis estimates that 24 000 people are currently sleeping rough in the UK, substantially more than the official figure of 4751.2 The charity also estimated that 82 310 households were in temporary accommodation on 30 June 2018, an increase of 71% since the low of 48 010 in 2010. This included 130 000 children.2

Homeless people present to NHS services with histories of poverty and deprivation, neglect and abuse in childhood,3 educational exclusion, and contact with the criminal justice system.34 Alongside childhoods dominated by adverse events, people experiencing homelessness are also highly likely to have other physical or psychological conditions, including undiagnosed acquired brain injury, autism, or attention deficit/hyperactivity disorder; poor oral health; chronic back pain; obstructive pulmonary diseases; and cognitive deficits arising from poor nutrition and alcohol use.5

Homeless people experience some of the highest rates of bloodborne virus infections and tuberculosis. Rates of suicide and death from violence are extremely high.5 To this, we can add the serious psychological problems that so often result from negative early years’ experiences, along with problematic substance misuse.

Healthcare response

So what needs to happen? Homeless people need healthcare professionals to support them in trusting, sustained relationships, and in developing care plans that prioritise their most pressing concerns, delivered by strong multidisciplinary teams. A wide variety of health professionals should be involved, including occupational therapists, physiotherapists, psychologists, dentists, podiatrists, and optometrists.

The Pathway model for homeless healthcare (www.pathway.org.uk) is becoming more established in the UK. Rooted in primary care, teams with expertise in homelessness reach into hospitals and where possible recruit trained former homeless people as “experts by experience.” A growing network of clinicians and researchers is being supported in the Pathway model through standards driven by the Faculty for Homeless and Inclusion Health.6 Initiatives such as London’s mobile Find and Treat service (www.uclh.nhs.uk/ourservices/servicea-z/htd/pages/mxu.aspx) are targeting tuberculosis and hepatitis C in excluded and hidden populations. Excellent results are being achieved by fully integrated services working in primary and secondary care and on the streets.7

The NHS long term plan highlights homelessness as a fundamental health equity challenge.8 The next step is to join up fragmentary good practice and roll out the service models known to be effective. Every major city needs an “inclusion health” clinical network. Services need permission and support to cross administrative boundaries and join up around their patients. Joint planning and delivery are needed with local authorities, criminal justice agencies, and the voluntary and community sectors. The Homelessness Reduction Act 2017 places a duty on health services to refer homeless people to local housing authorities. This duty is not widely understood or implemented.9

Policy failure

The current crisis of homelessness has arisen from a perfect storm of rent rises, cuts to welfare and support services, and the lack of social housing.10 Initiatives such as the Housing First movement in Finland (https://housingfirsteurope.eu/) and Canada’s Homes First (https://homesfirst.on.ca) may have potential in the UK. Both focus on housing homeless people in housing developments as the fundamental core component of any package of support, as do self build housing projects in England.11

There have been failures in UK housing policy over many decades. The UK has 27.2 million households12 and roughly 28 million dwellings.13141516 This tight relation between availability and demand creates scarcity, regional disparities, and upward pressure on rents. For 40 years there has been no political will to build truly affordable social housing. Current austerity policies have affected the weakest in society the most—benefit cuts, sanctions, and obstructive processes combining to deny people the basic means to survive. Destitution is the reality for many.17

The health harms that we see in people made homeless are driven by social and economic inequality. The health service is picking up the pieces, and by doing that better we can save some lives and mitigate some of the damage. But in the long term we need radical change in housing, education, criminal justice, welfare, and economic policy. Homelessness is a serious healthcare problem, but it is the consequence of political choices.

Footnotes

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet2018;391:241-50.doi:10.1016/S0140-6736(17)31869-Xpmid:29137869